1. Chp 8 Medical Ethical Cases RED means the case is exactly the kind I WON’T put on a Scantron test.

2. Patient: Herbert Orr, 75, Male Symptoms: leg pain, shortness of breath, frequent mental impairment, and mild left-sided weakness. His past history includes coronary artery bypass surgery, with complications requiring five months of hospitalization (two months of dialysis and a lengthy stay in the ICU). The patient says he wants to "die and go to God." His wife prefers that he continue dialysis and live, no matter how impaired he is. Diagnosis: pulmonary embolus, with a strong possibility of stroke in the future, and renal failure Treatment(s) proposed: dialysis

3. Patient: Herbert Orr, 75, Male Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

4. Patient: George, 27, Male Symptoms: George has had fever, headache, diarrhea, constipation, and rash for a month. His wife has been diagnosed with the same illness, but in her case it is too late, it is terminal. She has been sent to die at an island asylum for Typhus cases. Though George's sickness could be cured with antibiotics, he wants to go to the island asylum and die there with his wife. Diagnosis: Typhoid fever Treatment(s) proposed: antibiotics

5. Patient: George, 27, Male Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

6. Patient: Alcibiades Moreno, 37, male Symptoms: He fell 47 stories off a window washer platform. He's severely busted up: broken bones, crushed organs, severe blood loss, in a coma. Diagnosis: massive trauma Treatment(s) proposed: He needs immediate lifesaving surgery. His recovery will be long and include many surgeries, blood transfusions and organ transplants.

7. Patient: Alcibiades Moreno, 37, male Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

8. Patient: George Sherill, 69, Male Symptoms: has a history of alcoholism, depression and mania; has had a stroke and two heart attacks; his kidney function is declining and his lungs are deteriorating Diagnosis: bipolar, alcoholic, heart disease, kidney disease, lung disease Treatment(s) proposed: intubation (tube inserted in his windpipe to drain lung fluid)

9. Patient: George Sherill, 69, Male Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

10. Patient: Aziza (Somali immigrant), 22, Female Symptoms: Coughing up blood. She has refused any treatment because she says she wants to die. Diagnosis: pulmonary tuberculosis that had spread past her lungs, and she has depression. Treatment(s) proposed: Standard drug therapy (pills taken orally) would cure the tuberculosis. The hospital offers the pills free of charge. If she waits any longer than her disease will become incurable.

11. Patient: Aziza (Somali immigrant), 22, Female Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

12. Patient: Daniel Hauser, 13, male Symptoms: cancerous tumors Diagnosis: Hodgkin’s lymphoma Treatment(s) proposed: Chemotherapy offers a 90% cure rate, but without chemotherapy the patient has only a 5% chance of survival. The patient's family has chosen alternative treatments due to their religious convictions. A judge ruled that the family must get medical treatment for their son.

13. Patient: Daniel Hauser, 13, male Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

14. Patient: Herbert Herb III, 57, male Symptoms: short temper, trouble speaking, dementia, loss of muscle control on his left side Diagnosis: stroke Treatment(s) proposed: blood thinners to dissolve the clot and prevent future clots

15. Patient: Herbert Herb III, 57, male Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

16. Patient: Ed, 67, male Symptoms: mental disability, hearing impairment, high blood pressure, diabetes, vision impairment. He also has a defective esophagus, and he often inhales his food and drink when trying to swallow. He sometimes develops aspirate pneumonia. Diagnosis: aspirate pneumonia Treatment(s) proposed: antibiotics to treat the pneumonia. The doctor also wants to put him (temporarily) on a feeding tube and a ventilator, to allow his lungs to heal. Ed doesn’t want a ventilator, but Ed is not competent. Bert, Ed's brother, invokes Ed's medical durable power of attorney, and must decide whether to accept or reject the treatment plan.

17. Patient: Ed, 67, male This case is ambiguous. If the pneumonia is not-so-bad and infrequent, then… Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

18. Patient: Baby Jane Doe, newborn, female Symptoms: rocker-bottom feet, heart murmur, enlarged heart, congenital heart defect, esophageal defect Diagnosis: Trisomy 18 Syndrome Treatment(s) proposed: during the early development of the child, provide fluids, electrolytes, and oxygen; remove carbon dioxide from blood; after this phase, the child may live for several years with moderate care

19. Patient: Baby Jane Doe, newborn, female OEM: for the “incubation phase” procedures Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary Nutrition/Hydration: obligatory

20. Patient: Madisyn Whitfield, 25, Female Symptoms: back pain, chills, and fatigue Diagnosis: Crohn’s disease and kidney stones Treatment(s) Proposed: feeding tube, percutaneous nephrolithotomy (surgical removal of stones)

21. Patient: Madisyn Whitfield, 25, Female OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary Nutrition/Hydration: obligatory

22. Patient: Krista Stryland, 32, Female Symptoms: obesity, lack of exercise, diet, depression Diagnosis: insufficient metabolism, obesity Treatment(s) proposed: liposuction (which will require lengthy recovery)

23. Patient: Krista Stryland, 32, Female We kicked this case around and considered various possibilities. Really, the medical facts are insufficient. Liposuction is just one of many possible treatments.

24. Patient: Nancy Cruzan, 32, Female Symptoms: displays motor reflexes but no indication of cognitive function, cannot breathe on her own Diagnosis: persistent vegetative state, in which she can live for years Treatment(s) proposed: ventilator, and provide nutrition by feeding tube

25. Patient: Nancy Cruzan, 32, Female OEM: for the ventilator Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary Nutrition/Hydration: obligatory if the ventilator is KEPT ON, optional if it is taken OFF.

26. Patient: Monica, 36, Female Symptoms: loss of muscle control and eventual suffocation due to loss of control over respiratory muscles Diagnosis: motor neurone disease (motor nerves fail, and the patient cannot control her movements; the mind is virtually unaffected). People with MND usually die of suffocation within 4 years of the onset of the disease. Monica's condition has steadily declined. She is not expected to live through the month, and is worried about the pain that she will face in her final hours. Treatment(s) proposed: She asks her doctor to give her morphine for pain if she begins to suffocate or choke. This will lessen her pain, but it will also hasten her death because it lowers respiration.

27. Patient: Monica, 36, Female PDE: for the morphine (DI: pain control) Criterion #1 Pass (II: breathing suppressed) Criterion #2 Pass Criterion #3 Pass Conclusion Good to do OEM: Criterion #1 Pass, however the real benefit is pain management Criterion #2 Pass Criterion #3 Pass Conclusion Pass but still optional. Pain management here is optional because it does not offer an increase of health…it’s a different kind of “real benefit.”

28. Patient: Terri Schiavo, 41, Female Symptoms: Suffered a full cardiac arrest, followed by coma Diagnosis: Coma, persistent vegetative state Treatment(s) proposed: Physical therapy; experimental therapy; remove feeding tube so that she dies

29. Patient: Terri Schiavo, 41, Female Nutrition/Hydration: obligatory Note: she’s NOT DYING of anything. Depriving her of food and water IN ORDER to kill her is HOMICIDE.

30. Patient: Piña Colada, 78, Female Symptoms: jaundice, abdominal pain, history of alcoholism Diagnosis: cirrhosis of the liver Treatment(s) proposed: liver transplant; note that the patient does not have health insurance to cover this expensive procedure, and she also lives in a remote area, meaning she would have to travel a great distance to undergo the transplant

31. Patient: Madisyn Whitfield, 25, Female OEM: Criterion #1 Pass Criterion #2 Fail Criterion #3 Fail Conclusion Extraordinary

32. Patient: Dax Cowart, 25, male Symptoms: Burned over 65% of his body from a freak accident, with irreparable damage to his eyes, ears and hands. Dax has attempted suicide many times and repeatedly attempted to refuse treatment. He has been treated against his will because it was not clear that he was competent. Now that he is able to communicate better, he is expressing his refusal of treatment, and he is clearly competent. Diagnosis: extensive burns Treatment(s) proposed: Large doses of narcotics for minimal pain relief, regular baths in a chlorinated water to fight infection, and numerous bandages covering his body, replaced daily. Long-term recovery will require many surgeries to repair his skin.

33. Patient: Dax Cowart, 25, male Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

34. Patient: Walter White, 50, Male Symptoms: cough, shortness of breath, chest pain, coughing up blood, blurred vision, headaches, seizures, and symptoms of stroke Diagnosis: small-cell lung cancer Treatment(s) proposed: Chemotherapy leading to surgical removal of the cancer. Note that the patient’s insurance company will only cover a small portion of the vast expense of treatment. On the one hand, Walter does not want to plunge his family into debt. On the other hand, Walther does not want to leave his children without a father. Walther never smoked but is a chemist, and has been in contact with many dangerous chemicals during his career.

35. Patient: Walter White, 50, Male Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

36. Patient: Karen Ann Quinlan, 21, Female Symptoms: Patient became unconscious after arriving home from a party. She had consumed diazepam, dextropropoxyphene and alcohol. She collapsed. Twice she stopped breathing for 15 minutes or more. Her brain damage is profound and permanent. After a few months, her parents want to remove the ventilator. Diagnosis: she needs a ventilator to breathe for her; also, persistent vegetative state Treatment(s) proposed: ventilator

37. Patient: Karen Ann Quinlan, 21, Female OEM: for the ventilator Criterion #1 Pass Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary Nutrition/Hydration: obligatory if the ventilator is KEPT ON, optional if it is taken OFF.

38. Patient: Vera Lynn, 78, Female Symptoms: confusion, poor judgment, mood swings, unable to retain information, frequently falls, recently had a four month hospital stay for pneumonia, and has had prior strokes. Her confusion makes her difficult to care for, and she is often dehydrated. Diagnosis: severe dementia, diabetes with impaired vision, poor kidney function Treatment(s) proposed: IV fluids

39. Patient: Vera Lynn, 78, Female The medical facts are a little ambiguous, but we interpreted the kidney function to be poor, but still working and not declining. If the kidneys were failing, the analysis would be different. Nutrition/Hydration: obligatory

40. Patient: Jayden Aldona Gonzalez, 20 months, male Symptoms: vomiting, head pain, unsteadiness Diagnosis: aggressive brain tumor Treatment(s) proposed: transported to Children’s Hospital of Philadelphia for surgery to remove the tumor

41. Patient: Jayden Aldona Gonzalez, 20 months, male OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

42. Patient: Chris Sands, 24, Male Symptoms: Hiccups as often as every two seconds a day and cannot stop. Because of this, he has been limited in his ability to be a back-up singer in his band, “Ebullient.” Diagnosis: The doctors aren’t sure, but suspect he has an acid reflux condition caused by a damaged valve in his stomach. Treatment(s) proposed: Keyhole surgery to grab part of Chris’s stomach and wrap it around the valve to tighten it.

43. Patient: Chris Sands, 24, Male OEM: Criterion #1 Fail Criterion #2 Pass Criterion #3 Pass Conclusion Extraordinary If, however, the doctors became sure of the diagnosis, the analysis might be different.

44. Patient: Malcolm, 64, male Symptoms: shortness of breath; a tumor is compressing his airways to both lungs. Aggressive treatment of the tumor has failed. The tumor has not shrunk. He was put on a ventilator to assist breathing. The doctors judge that his condition cannot be improved. He becomes incompetent. His wife wants to do everything possible to extend Malcolm’s life. The hospital is bearing the majority of the cost of his care. Diagnosis: Incurable, terminal cancer of the esophagus Treatment(s) proposed: Ventilator

45. Patient: Malcolm, 64, male OEM: for the ventilator Criterion #1 Pass (assists breathing) Criterion #2 Pass Criterion #3 Fail Conclusion Extraordinary

46. Patient: Lauren Richardson, 23, Female Symptoms: a heroin overdose caused her to fall unconscious and stop breathing. Lack of oxygen severely damaged her brain. She is in a coma. She is provided nutrition and hydration artificially. She has no health insurance. Diagnosis: Anoxic brain injury, persistent vegetative state Treatment(s) proposed: Removing nutrition and hydration

47. Patient: Lauren Richardson, 23, Female Nutrition/Hydration: Obligatory NOT an OEM CASE!!!

48. Patients: Rital and Ritag Gaboura, 11 months, (both) Female Symptoms: Conjoined twins. Ritag’s heart is failing. Untreated, both will die. Diagnosis: Vertical Craniopagus, which means they are conjoined at the top of the skull and live at a 180 degree angle to one another. Heart failure (Ritag). Treatment(s) proposed: Surgical separation. The operation will be very long and risky, but both may be saved.

49. Patients: Rital and Ritag Gaboura, 11 months, (both) Female We analyze this as two sick people who may be saved by a long, difficult, risky surgery: – Pass, Pass, Fail, Extraordinary What makes this case simple but still very hard to analyze is the fact that both will die without the surgery, and both might live with the surgery. Still, the surgery is radical and involves profound physical burden, so it’s optional.

50. Patient: Milagros Cerron, 9 months, female Symptoms: She is born with a rare defect, born with several organs only partially formed or missing. Because her legs are conjoined, she has the appearance of a “mermaid.” Diagnosis: sirenomelia Treatment(s) proposed: Since this defect is very rare, and is usually fatal within two days of birth, there is very little medical technology and experience treating it. First, the doctors will insert silicone bags between her legs to expand the tissue in her legs and abdomen. Then they will perform surgery to separate her legs. She has all the bones and structures of normal legs, and she might walk one day. However, her internal organs cannot not grow properly because of her deformity. She has only one functioning kidney. She is in constant danger of infection, and she may at best live a few years. The cost of her care is covered by the city of Lima, Peru.

51. Patient: Milagros Cerron, 9 months, female This case looks complicated but it’s really pretty simple. Criterion #1 Pass (offers survival and improved function) Criterion #2 Fail because the doctors have limited technology and experience with this procedure. They’re inventing the procedure (RARE). Criterion #3 Fail because the surgery is radical and physically demanding, and because the city of Lima, Peru is opting freely to pay for it Conclusion Extraordinary

52. Patient: Billy Thompson, 9, Male Symptoms: Ear infections, pneumonia, asthma, neck pain, headaches Diagnosis: Tourette’s syndrome, insomnia; during an examination, the doctor discovered a neck injury Treatment(s) proposed: neck surgery. Repairing the injury should reduce the Tourette’s tics, decrease the neck pain and headaches.

53. Patient: Billy Thompson, 9, Male OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

54. Patient: Gretchen, 25, Female Symptoms: perfectly healthy; wants breast implants to advance her modeling career Diagnosis: none Treatment(s) proposed: silicon implants to augment breasts

55. Patient: Gretchen, 25, Female OEM: Criterion #1 Fail Criterion #2 Pass Criterion #3 Pass Conclusion Extraordinary, in the sense that she has no obligation to accept the procedure…but I argue that she has an obligation NOT TO GET the procedure

56. Patient: Gretchen, 26, Female Symptoms: Blurred vision, trouble retaining information, memory loss, body tingles and dizziness, muscle and joint pain, extreme anxiety and depression, skin rashes, tremors, and extreme fatigue Diagnosis: complications arising from silicon breast implants Treatment(s) proposed: remove the silicon implants; treat any infections discovered during surgery

57. Patient: Gretchen, 26, Female OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

58. Patient: Dick Cheney, 69, Male Symptoms: Suffered five heart attacks since 37 years old, chest pains Diagnosis: Progressive congestive heart failure Treatment(s) proposed: Implantation of a left ventricular heart assistance device (pump that takes over some of the heart’s work), until a transplant can be performed.

59. Patient: Dick Cheney, 69, Male OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

60. Patient: Gandalf, about 4000 years, male Symptoms: Patient started smoking a pipe when he was young. Now he has a cough, fatigue, and failing respiration. He has battled lung cancer for years with chemotherapy and radiation. Diagnosis: terminal lung cancer Proposed treatment(s): Chemotherapy and radiation can no longer help him. The doctor estimates that he will die of cancer in six days. Ever dignified, he requests that his IV hydration and his feeding tube be removed, so he can be more comfortable. The doctor says that dehydration can kill him in four days, and starvation in eight days.

61. Patient: Gandalf, about 4000 years, male Hydration: obligatory Nutrition: optional Cancer will kill him AFTER dehydration would but BEFORE starvation would.

62. Patient: Mary, 19, female Symptoms: high levels of anxiety and rapid mood swings Diagnosis: bipolar disorder Treatment(s) proposed: a prescription medication (lithium bicarbonate) taken twice daily will reduce the severity of her depressive and manic episodes; however, the pills have side effects including headaches and sometimes nausea

63. Patient: Mary, 19, female OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary

64. Patient: Brittney Lee, 24, Female Symptoms: abdominal pain Diagnosis: abdominal aortic aneurysm, a weakening in the wall of the thoracic aorta which causes it to stretch and bulge Treatment(s) proposed: surgery to repair the aorta (without which she will die). The scar left by the surgery will definitely end her career as a provocative dancer. She is paid to be an objectified stage decoration for touring performers such as Kenya East and 37 Cent.

65. Patient: Brittney Lee, 24, Female OEM: Criterion #1 Pass Criterion #2 Pass Criterion #3 Pass Conclusion Ordinary Note: her motive for claiming “emotional burden” is disordered…that’s one job she OUGHT to lose!

66. Patient: Ms. Bones, 18, female Symptoms: low energy, anxiety, fertility cycle stopped, muscle atrophy, aching joints; patient wants to fit into a size zero dress for prom Diagnosis: malnutrition Treatment(s) proposed: increase caloric intake, counseling; involuntary commitment if necessary

67. Patient: Ms. Bones, 18, female Nutrition/Hydration: obligatory She wants to starve herself for vanity’s sake. Duh. Go eat something.